New Approaches to Caries
Prevention and Control
Silver Nitrate, Silver
Diamine Fluoride
And Xylitol
Silver Nitrate
• Silver has been used medicinal since 1,000 B.C.
• Silver nitrate is used in medicine today for its effective
anti-microbial effect.
• Leaders in dentistry in the early part of the 20th Century,
G.V. Black, W.D. Miller and Percy Howe, utilized silver
nitrate to arrest active carious lesions.
• In the later 20th Century it fell in to disuse, potentially due
to the emphasis on eradicating caries and restoring the
tooth, not simply arresting the active caries process.
• The epidemic of dental caries in young children has
prompted a reassessment of silver nitrate as a means of
arresting dental caries in young children until that time at
which children can cooperate for having he teeth restored.
Silver Nitrate
Caries Arrestment Technique
• 25% Silver Nitrate (25% silver nitrate and 75%
water); Available from Henry Schein company at
www.HenrySchein.com
• In article by Duffin (see course website for article)
the technique of use calls for application of the
silver nitrate to an active carious lesion, followed by
placing 5% fluoride varnish over the treated lesion.
• Duffin suggests the placement of the fluoride
varnish prevents contact of the silver nitrate with
the soft tissue (it is caustic); provides a protective
layer to prevent the silver nitrate from being
immediately washed away by saliva; and adds the
preventive effect of fluoride.
Application Technique
Duffin recommends that the application be repeated at
two, four, eight and twelve weeks.
Silver Diamine Fluoride
• In several countries of the world, notably Brazil and Japan, a
compounded combination of silver nitrate and fluoride is
being used to prevent dental caries, as well as to arrest
lesions: silver diamine fluoride.
• It is marketed with a number of names and concentrations:
• Cariostatic (10% SDF); Cariestop (12% and 38% SDF), and
Saforide (38% SDF)
• Silver diamine fluoride has not yet been approved by the
FDA for use in the United States.
• A systematic review of the literature (Journal of Dental
Research) supporting the efficacy of silver diamine fluoride
is at the module’s webpage.
Contraindications
• History of any pain from the tooth,
indicating the lesion is approximating
or has invaded the pulp.
• Lack of sound dentin between the
lesion and the pulp.
• Evidence that the tooth is non-vital,
such as presence of a parulis (gum
boil).
Advantages and Disadvantages
• The carious lesion is arrested; though the structure,
function, and esthetics of the tooth is not restored.
• Caries is prevented from invading the pulp with subsequent
pain and loss of vitality of the pulp and the tooth requiring
extraction.
• In a very young uncooperative child arresting “early
childhood caries” can permit delaying restoration until the
child is older and able to cooperate for restoration of the
teeth.
• Currently, young children with dental caries who are
uncooperative have to be treated under general anesthesia
in a hospital or out patient surgical center. This is a very
expensive setting.
• Use of silver nitrate or a silver diamine fluoride regime is
“medical” rather than “surgical’ approach to treating caries.
Xylitol
• Xylitol, in the form or chewing gum or candy, is being used as
a significant caries preventive agent in Europe, particularly
in Scandinavia.
• Field trials in the late 1960s and early 1970 in Finland
demonstrated a significant caries preventive effect from
diets sweetened with Xylitol rather than sucrose.
• Xylitol is a sugar alcohol (polyol) with sweetness equal to
table sugar, but with 40% fewer calories. A primary source
of Xylitol is from the sap of birch trees.
• Xylitol is not fermented by plaque bacteria. Thus it reduces
accumulation of plaque on the teeth. Plaque pH does not drop
when xylitol sweetened gum is chewed, therefore
remineralization is enhanced.
• In Finland, school children typically chew Xylitol chewing gum
three times a day for five minutes as a caries preventive
regimen.
Xylitol
• Dental caries is an infectious disease.
• Infants are typically infected with mutans streptococci
from their mothers as a result of the exchange of saliva.
• Mothers with open carious lesions or poor oral hygiene infect
their children earlier with the microorganism. The earlier
the infection of infants the more vulnerable the child
becomes to dental caries.
• It is desirable to reduce the mutans streptococci load in
pregnant women. This is typically done by restoring carious
teeth, rinsing with chlorohexidine, and the use of high
potency topical fluoride.
Xylitol
• Xylitol reduces mutans strep counts; therefore,
use of xylitol chewing gum by pregnant women is
advocated as an additional preventive strategy in
reducing transmission of from mother to infant.
• In one study, in which mothers chewed xylitol gum
three times a day for three months before
delivery, their children had significantly lower
mutans steptococci counts than a control group,
even up to six years of age…and significantly less
caries experience than controls.
• Three articles on the use of Xylitol in preventing
dental caries are at the module’s webpage.